WPR22LA005

NTSB accident investigation · Beech B36TC · Los Banos, CA · October 9, 2021

Accident · No injuriesClass 3 · LimitedFinal report
Date
October 8, 2021, 19:04 local (Oct 9, 2021, 02:04 UTC)
Place
Los Banos, CA · 1 miles south in open terrain
Injuries
1 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N7220BBeech B36TC
Defining event
Enroute-cruise: Loss of engine power (total)
Weather
Visual (VMC) · Dusk
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20211008017449A
Case key
104084

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

The total loss of engine power due to the improper installation of the No. 4 connecting rod bolt nut during a recent overhaul.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

The pilot reported that he was on the return leg of a cross country flight, about 10,000 ft mean sea level, when the engine lost oil pressure and the manifold pressure dropped. He immediately diverted to the nearest airport. While in the descent to his divert location, the engine was initially producing partial power, but then exhibited serious vibrations and subsequently lost all power. During this time, the cockpit filled with smoke, and fire and sparks were observed exiting from the engine cowling. Due to the fire, the pilot elected to make a forced landing on a road near the approach end of runway. The airplane struck an object during the landing roll which resulted in substantial damage to the wings. A postaccident examination of the engine revealed that the No. 4 connecting rod bolt nut was missing. Prominent thermal distress was observed in the area where the No. 4 connecting rod connected to the crankshaft and was consistent with oil starvation. In June of 2020, the engine was disassembled for a propeller strike inspection. The inspection was about 27.3 hours before the accident. As part of the inspection, the connecting rods were overhauled and then reinstalled on the crankshaft using new bearings, rod bolts, and nuts. Given the recency of the work, it is likely that insufficient torque was applied during installation of the No. 4 connecting rod bolt nut, which subsequently became loose and separated.

Factual narrative

The factual narrative540 words

On October 8, 2021, about 1904 Pacific daylight time, a Beech B36TC airplane, N7220B, was substantially damaged when it was involved in an accident near Los Banos, California. The pilot was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he flew the airplane to Paso Robles Municipal Airport (PRB), Paso Robles, California, where he refueled and was on his return flight to Gnoss Field Airport (DVO), Novato, California, when the accident occurred. The airplane was at about 10,000 ft mean sea level when the engine lost oil pressure and the manifold pressure dropped. He immediately diverted to Los Banos Municipal Airport (LSN), Los Banos, California. While in the descent into LSN, the engine was initially producing partial power, but then exhibited severe vibrations and subsequently lost all power. During this time, the cockpit filled with smoke, and fire and sparks were observed coming from the engine cowling. Due to the fire, the pilot elected to make a forced landing on a road near the approach end of the runway. The airplane struck an object during the landing roll, which caused the airplane to spin around before coming to rest. A review of engine data from a Garmin G500TXi device revealed that the airplane leveled off and the engine was set to about 2,500 rpm. About 9 minutes later, the engine’s oil pressure started to decrease, while the engine rpm was unchanged. In the next 12 minutes, the oil pressure continued to decrease and culminated with the engine rpm decreasing from about 2,371 to zero rpm in about 5 seconds while the airplane was in a descent. Postaccident examination of the engine revealed external damage with an exit hole on the crankcase near the top of the No. 2 cylinder. The hole was about 2 inches wide by 3 inches long. A second hole in the crankcase was noted on the left back side that had a diameter of about 1 inch. Additionally, several large cracks in the crankcase were observed on both crankcase halves. All engine accessories on the back side of the engine remained attached except for the left magneto. The rocker covers were removed and there was evidence of heat distress on all cylinders. Rotational continuity could not be established due to the crankshaft damage. Disassembly of the engine revealed that the No. 4 connecting rod bolt nut was missing. Thermal distress was observed in the area where the No. 4 connecting rod connected to the crankshaft, consistent with oil starvation. The thermal distress in this area was the most prominent in the engine. Considerable metal debris was noted in the oil sump and oil filter. The engine was installed in July of 2012, and logged about 671 hours of time before the accident. In June of 2020, the engine was disassembled for a propeller strike inspection. The inspection was about 27.3 hours before the accident. As part of the inspection, the connecting rods were overhauled by a third-party vendor, andthen the vendor reinstalled the connecting rods on the crankshaft using new bearings, rod bolts, and nuts. The most recent annual inspection was accomplished in September of 2021, about 2.3 hours before the accident.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft

Registration
N7220B
Reported as
Beech B36TC
Category
Airplane
Serial number
EA-425
Built
1984
Airframe hours
5,356.9
Engine
Continental IO550B-AP, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Business · Part 91
Registered owner
6l6 LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 8, 2021
Departed
PRB · Paso Robles, CA
Destination
DVO · Novato, CA
Flight plan
IFR
Airport
LSN · Los Banos Muni
Equipment
Onboard weather, Stall warning system, ADS-B, Auto-pilot, Electronic multifunction display, Electronic primary flight display

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
43
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
March 15, 2021
Seat
Left
Restraint
3-point
Flight hours
1,353.3 total · 927.6 in this make and model · 1,469.6 as pilot in command · 17.3 in the last 90 days · 3.8 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Dusk
Wind
230° at 8 knots, gusting 14
Visibility
10 statute miles
Temperature
57 °F, dew point 46 °F
Altimeter
30.14 inHg
Observed at
KCVH, 28 nm away
METAR
KCVH 090215Z AUTO 23008G14KT 10SM FEW050 14/08 A3014 RMK A01

Docket · 5

The files NTSB released with the investigation on October 19, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.4 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.